1. CatatoniaCatatoniaJay A. Yeomans, MDJay A. Yeomans, MD
CMC-R, BHC Grand RoundsCMC-R, BHC Grand Rounds
February 1February 1stst
, 2010, 2010

3. Encephalitis Lethargica …Encephalitis Lethargica … (“sleepy(“sleepy sickness”)sickness”)
worldwide epidemic: 1915-1926 … Oliver Sachs: Bronx Hospital : L-Dopaworldwide epidemic: 1915-1926 … Oliver Sachs: Bronx Hospital : L-Dopa
??????Post strep immune response … IgG autoantibodies reactive to basal ganglia antigensPost strep immune response … IgG autoantibodies reactive to basal ganglia antigens
similar to Sydenham’s chorea & PANDAS (ped autoimmune neuropsych assoc w/ strep)similar to Sydenham’s chorea & PANDAS (ped autoimmune neuropsych assoc w/ strep)
- some historians have advanced the idea that EL is the explanation for the sxs that- some historians have advanced the idea that EL is the explanation for the sxs that
afflicted the NE during the 17afflicted the NE during the 17th Centuryth Century
leading to the Salem Witch Trialsleading to the Salem Witch Trials

4. HistoryHistory
► Karl KahlbaumKarl Kahlbaum (1874): “melancholia attonita” –(1874): “melancholia attonita” –
cerebral disorder accompanied by mental,cerebral disorder accompanied by mental,
physical, & behavioral symptomsphysical, & behavioral symptoms
-sx complex characterized by negativism, catalepsy,-sx complex characterized by negativism, catalepsy,
mutism, stereotypy, posturing, muscle rigidity &mutism, stereotypy, posturing, muscle rigidity &
verbigeration – pts alternated between catatonicverbigeration – pts alternated between catatonic
stupor & excitementstupor & excitement
► Emil KraepelinEmil Kraepelin (1893) included catatonic sxs in(1893) included catatonic sxs in
his description ofhis description of dementia praecoxdementia praecox –– includedincluded
catatonia with paranoid & hebephreniacatatonia with paranoid & hebephrenia

6. HistoryHistory
► Eugen BleulerEugen Bleuler (1911) included catatonic(1911) included catatonic
symptoms in his description of a subtype ofsymptoms in his description of a subtype of
schizophreniaschizophrenia – “splitting of the psychic function”– “splitting of the psychic function”
catatonic condition be considered schizophrenia onlycatatonic condition be considered schizophrenia only
in the presence of 4 primary sxs - disturbance inin the presence of 4 primary sxs - disturbance in
AAssociation &ssociation & AAffect, & manifestations offfect, & manifestations of
AAmbivalence &mbivalence & AAutism (utism (four “As”four “As”))
► Karl LeonardKarl Leonard (1957) was the first to identify(1957) was the first to identify
catatonia as belonging to other psychiatriccatatonia as belonging to other psychiatric
disorders; e.g. Schizophrenia, affective psychosisdisorders; e.g. Schizophrenia, affective psychosis
& cycloid psychosis& cycloid psychosis

7. HistoryHistory
►Alan GelenbergAlan Gelenberg (1976):(1976):
““The Catatonic Syndrome”The Catatonic Syndrome” ((LancetLancet, June ‘76), June ‘76)
Catatonia often assumed to be a subtype ofCatatonia often assumed to be a subtype of
Schizophrenia … proposed that it beSchizophrenia … proposed that it be
considered aconsidered a syndromesyndrome with variouswith various
possible causes …possible causes …
► SchizophreniaSchizophrenia
► Affective illnessAffective illness
► NeurosesNeuroses

8. HistoryHistory
Gelenberg:Gelenberg: “The Catatonic Syndrome”“The Catatonic Syndrome”
► NeurologicalNeurological;; limbic system, temporal lobes, &limbic system, temporal lobes, &
other brain lesions (vascular, infectious, traumaticother brain lesions (vascular, infectious, traumatic
& malignant)& malignant)
► MetabolicMetabolic;; DM, hypercalcemia, hepaticDM, hypercalcemia, hepatic
encephalopathy, homocystinuriaencephalopathy, homocystinuria
► ((ViralViral, e.g. HIV /, e.g. HIV / AutoimmuneAutoimmune, e.g. Encep Letharg), e.g. Encep Letharg)
► ToxicToxic;; illuminating gas & organic fluoridesilluminating gas & organic fluorides
► PharmacologicPharmacologic;; ASA, ACTH, neuroleptics,ASA, ACTH, neuroleptics,
disulfiram, mescaline, amphetamine, ethyl EtOH &disulfiram, mescaline, amphetamine, ethyl EtOH &
PCPPCP

9. Catatonia (DSM)Catatonia (DSM)
DSM-II ‘68DSM-II ‘68:: Schizophrenia; catatonic type, excitedSchizophrenia; catatonic type, excited
(295.23) / withdrawn (295.24)(295.23) / withdrawn (295.24)
DSM-III-R ‘87DSM-III-R ‘87: still no ‘Secondary Catatonic: still no ‘Secondary Catatonic
Disorder’Disorder’
DSM-IV-TR ‘00:DSM-IV-TR ‘00:
Catatonia as aCatatonia as a subtypesubtype of Schizophrenia (295.20)of Schizophrenia (295.20)
AA specifierspecifier for mood disorders (BAD, MDD)for mood disorders (BAD, MDD)
DisorderDisorder d/t a General Medical Conditiond/t a General Medical Condition (293.89)(293.89)

10. CatatoniaCatatonia
DSM-IV-R: Criteria:DSM-IV-R: Criteria: specifierspecifier for mood disorders (2/5) &for mood disorders (2/5) &
DisorderDisorder d/t a GMCd/t a GMC (1/5)(1/5)
(1)(1) Motoric immobilityMotoric immobility AEB catalepsy (incl. waxy flexibility) or stuporAEB catalepsy (incl. waxy flexibility) or stupor
(2)(2) Excessive motor activityExcessive motor activity (purposeless & not influenced by external stimuli)(purposeless & not influenced by external stimuli)
(3)(3) Extreme negativismExtreme negativism (motiveless resistance)(motiveless resistance)
(4)(4) Peculiarities of voluntary movementsPeculiarities of voluntary movements (posturing, stereotyped movements)(posturing, stereotyped movements)
(5)(5) EchophenomenaEchophenomena (echolalia or echopraxia)(echolalia or echopraxia)
No duration criteria or frequencyNo duration criteria or frequency
Mutism & stupor principle signs, but not pathogonomonicMutism & stupor principle signs, but not pathogonomonic
Cataplexy, mannerisms, posturing & mutism most often present in SchizophreniaCataplexy, mannerisms, posturing & mutism most often present in Schizophrenia

11. CatatoniaCatatonia
Epidemiology:Epidemiology:
5%5% -17% of acute / hospitalized psychiatric patients-17% of acute / hospitalized psychiatric patients
Mood Disorders:Mood Disorders: 13% -13% - 49%49% (Bipolar mania)(Bipolar mania)
Schizophrenias:Schizophrenias: 10%10% -- 15 %15 %
…… decline d/t change in dx practice (decline d/t change in dx practice (↑↑ undifferentiated & paranoid ;undifferentiated & paranoid ; ↓↓ hebephrenichebephrenic
& catatonic) or misdiagnosis (i.e. misdx of mood disorders as schizophrenia)& catatonic) or misdiagnosis (i.e. misdx of mood disorders as schizophrenia)
Organic Disorders:Organic Disorders: 4% - 46%4% - 46%
In adults,In adults, womenwomen are more common in reported series ofare more common in reported series of
cases of catatoniacases of catatonia

12. CatatoniaCatatoniaChildren & AdolescentChildren & Adolescent
 presentation similar as in adults …exceptpresentation similar as in adults …except malesmales
overrepresented in assoc. w/psych disordersoverrepresented in assoc. w/psych disorders
 occurs w/ affective, psychotic, *autistic,occurs w/ affective, psychotic, *autistic,
*developmental (e.g. MR), drug-induced & medical*developmental (e.g. MR), drug-induced & medical
conditions…conditions… *Autism & PDD commonly assoc with catatonia*Autism & PDD commonly assoc with catatonia
 Ponitz ‘13: “early catatonia” / Leonard: “infantile catatonia”Ponitz ‘13: “early catatonia” / Leonard: “infantile catatonia”
 In psych population; estimated f = 0.6% – 17% ofIn psych population; estimated f = 0.6% – 17% of
admissions to psych facilitiesadmissions to psych facilities
(adults w/estimated f = 7.6% - 38%)(adults w/estimated f = 7.6% - 38%)
Taylor & Fink.Taylor & Fink. Am JAm J PsychiatryPsychiatry. 2003; 160 (7):1223-1241. 2003; 160 (7):1223-1241
 TreatmentTreatment of underlying psych / med condition, eg, SGAsof underlying psych / med condition, eg, SGAs
(monitor for NMS) for Schizo, ECT or lithium for BAD,(monitor for NMS) for Schizo, ECT or lithium for BAD,
Barbs, BZDs etc.Barbs, BZDs etc.

13. CatatoniaCatatonia
Differential Dx:Differential Dx:
Elective mutismElective mutism
akinetic Parkinson’s diseaseakinetic Parkinson’s disease
Locked-in syndromeLocked-in syndrome
Stiff-person syndromeStiff-person syndrome
Malignant hyperthermiaMalignant hyperthermia
Brainstem diseaseBrainstem disease
Stupor d/t metabolic derangementStupor d/t metabolic derangement
Non-convulsive status epilepticusNon-convulsive status epilepticus
Conversion disorderConversion disorder
d/t antihistamine OD;d/t antihistamine OD; withdrawalwithdrawal from levodopa,from levodopa,
amantadine, BZDs, clozapine & AEDsamantadine, BZDs, clozapine & AEDs

14. CatatoniaCatatonia
Clinical Exam:Clinical Exam:
Mutism …Mutism … verbally unresponsiveverbally unresponsive
Stupor …Stupor … unresponsive, hypoactiveunresponsive, hypoactive
Echophenomena …Echophenomena … echolalia & echopraxiaecholalia & echopraxia
Stereotypy …Stereotypy … non-goal-directed, repetitivenon-goal-directed, repetitive
motor behavior (verbal :motor behavior (verbal : verbigerationverbigeration))
Mannerisms …Mannerisms … odd, purposeful movementsodd, purposeful movements
Ambitendency …Ambitendency … ‘stuck’ in a indecisive,‘stuck’ in a indecisive,
hesitant movementhesitant movement

15. CatatoniaCatatonia
Clinical Exam: cont.Clinical Exam: cont.
NegativismNegativism (gegenhalten)(gegenhalten) … resist… resist
examiner’s manipulations with strengthexaminer’s manipulations with strength
equal to that appliedequal to that applied
PosturingPosturing (catalepsy)(catalepsy) …… maintains posturesmaintains postures
for long periods, e.g. facial & body posturesfor long periods, e.g. facial & body postures
Waxy Flexibility …Waxy Flexibility … initially resist examiner’sinitially resist examiner’s
manipulations then allows him-/herself tomanipulations then allows him-/herself to
be postured (bending candle)be postured (bending candle)
Automatic Obedience …Automatic Obedience … despite instructionsdespite instructions
to the contrary, pt permits the examiner’sto the contrary, pt permits the examiner’s
light pressure to move the pt’s limbs into alight pressure to move the pt’s limbs into a
new posturenew posture

16. Rating ScalesRating Scales
Bush-Francis Catatonia Scale (’93)Bush-Francis Catatonia Scale (’93)
23 item (scored 0-3)23 item (scored 0-3)
► ExcitementExcitement
► Immobility/stuporImmobility/stupor
► MutismMutism
► StaringStaring
► Posturing/catalepsyPosturing/catalepsy
► GrimacingGrimacing
► Echopraxia/echolaliaEchopraxia/echolalia
► StereotypyStereotypy
► MannerismsMannerisms
► VerbigerationVerbigeration
► RigidityRigidity
► NegativismNegativism
► Waxy flexibilityWaxy flexibility
► WithdrawalWithdrawal
► ImpulsivityImpulsivity
► Automatic obedienceAutomatic obedience
► MitgehenMitgehen
► GegenhaltenGegenhalten
► AmbitendencyAmbitendency
► Grasp reflexGrasp reflex
► PerseverationPerseveration
► CombativenessCombativeness
► Autonomic abdnormalityAutonomic abdnormality

17. CatatoniaCatatonia
Electrophysiologic FindingsElectrophysiologic Findings
► Catatonic features in seizuresCatatonic features in seizures
► Louis & Pfaster ’95 postulatedLouis & Pfaster ’95 postulated
““non-ictal paroxysmal subcortical dysrhthmia”non-ictal paroxysmal subcortical dysrhthmia”
(alteration in alpha rhythm)(alteration in alpha rhythm)
► There are no consistent EEG abnl in catatoniaThere are no consistent EEG abnl in catatonia
MRCPMRCP (movement-related cortical potentials)(movement-related cortical potentials) abnormal in Catatonia /abnormal in Catatonia /
Parkinson’s Dz & NMSParkinson’s Dz & NMS
► Catatonia – inability to terminate movements (determinedCatatonia – inability to terminate movements (determined
by GABA)by GABA)
► Parkinson’s – inability to fully execute movementsParkinson’s – inability to fully execute movements
(determined by dopamine)(determined by dopamine)
► NMS – similar MRCP to Parkinson’s d/t striatal dopamineNMS – similar MRCP to Parkinson’s d/t striatal dopamine
deficiencydeficiency

18. CatatoniaCatatonia
 Brain (Neuro) imaging: (e.g. fMRI, PET):Brain (Neuro) imaging: (e.g. fMRI, PET):
functional alterations in the neural network betweenfunctional alterations in the neural network between
thethe R medial & lateral orbito-frontal cortices & theR medial & lateral orbito-frontal cortices & the
R posterior parietal cortexR posterior parietal cortex
 ? Subcortical (Basal Ganglia)…? Subcortical (Basal Ganglia)… generation ofgeneration of
movementsmovements
 *Cortical… catatonia is a*Cortical… catatonia is a psychomotor syndromepsychomotor syndrome
characterized by cortical dysfunction.characterized by cortical dysfunction.

19. CatatoniaCatatonia
Classification:Classification:
Acute / Periodic / ChronicAcute / Periodic / Chronic
Simple / Non-malignantSimple / Non-malignant
(‘lethal’)(‘lethal’) Malignant CatatoniaMalignant Catatonia (MC)(MC)
Neuroleptic Malignant Syndrome (NMS)Neuroleptic Malignant Syndrome (NMS)
(Toxic) Serotonin Syndrome (SS)(Toxic) Serotonin Syndrome (SS)

20. CatatoniaCatatoniaMalignant CatatoniaMalignant Catatonia (MC)(MC):: described long before the intro ofdescribed long before the intro of
antipsychoticsantipsychotics
 acute onset of excitement, delirium, fever, autonomic instability &acute onset of excitement, delirium, fever, autonomic instability &
cataplexycataplexy
 appear to have fulminant infectious diseaseappear to have fulminant infectious disease
 Medical EmergencyMedical Emergency
 Death rate up to 20% / frequent sustained morbidityDeath rate up to 20% / frequent sustained morbidity
 Medical complications include aspiration pneumonia, PE, urinaryMedical complications include aspiration pneumonia, PE, urinary
retention, decubitus ulcers, DVTretention, decubitus ulcers, DVT
Neuroleptic Malignant SyndromeNeuroleptic Malignant Syndrome (NMS):(NMS): applied when condition isapplied when condition is
associated with exposure to antipsychotic drugsassociated with exposure to antipsychotic drugs
 Up to 1% of patients treated with antipsychotic meds develop NMS –Up to 1% of patients treated with antipsychotic meds develop NMS –
usually in the first 2 wks of exposureusually in the first 2 wks of exposure
Serotonin SyndromeSerotonin Syndrome (SS)(SS): similar to MC, except with gastrointestinal: similar to MC, except with gastrointestinal
symptoms and prior exposure to serotinergic (5HT) medicationssymptoms and prior exposure to serotinergic (5HT) medications

21. CatatoniaCatatonia
Malignant Catatonia (MC)Malignant Catatonia (MC)
Neuroleptic Malignant SyndromeNeuroleptic Malignant Syndrome
(Delay, et al.; Ann Med Psychol; 1960; 118:145-152)(Delay, et al.; Ann Med Psychol; 1960; 118:145-152)
 Dx based on cardinal clinical features:Dx based on cardinal clinical features:
 severe muscle rigidity, hyperthermia, autonomic instabilitysevere muscle rigidity, hyperthermia, autonomic instability
& changes in levels of consciousness assoc. with the use& changes in levels of consciousness assoc. with the use
of antipsychotic medication.of antipsychotic medication.
 Leukocytosis & lab evidence of muscle injury, e.g.Leukocytosis & lab evidence of muscle injury, e.g. ↑↑ CPKCPK
 Frequency: primarily after use of FGAs, 2/3Frequency: primarily after use of FGAs, 2/3rdrd
w/in the firstw/in the first
wk, occurs in 0.07-2.2% of pts taking neurolepticswk, occurs in 0.07-2.2% of pts taking neuroleptics
 Mortality: 10-20%Mortality: 10-20%
 Race: no data to suggest racial variationRace: no data to suggest racial variation
 Sex: Incidence > in malesSex: Incidence > in males
 Age: Incidence > in persons younger than 40 yrs oldAge: Incidence > in persons younger than 40 yrs old

22. CatatoniaCatatonia
Malignant Catatonia (MC)Malignant Catatonia (MC)
Neuroleptic Malignant SyndromeNeuroleptic Malignant Syndrome
 conceptualized as a drug induced form of MCconceptualized as a drug induced form of MC
 Catatonia is a predisposing factor for NMSCatatonia is a predisposing factor for NMS
 Simple catatonia / MC / NMS share a commonSimple catatonia / MC / NMS share a common
pathophysiology involving reduced dopaminergicpathophysiology involving reduced dopaminergic
functioning in the basal ganglia-thalomocortical circuits, etcfunctioning in the basal ganglia-thalomocortical circuits, etc
 *Antipsychotics should be withheld if MC is suspected*Antipsychotics should be withheld if MC is suspected
 BZDs &/or ECT:BZDs &/or ECT: treatment of choicetreatment of choice
Bromocriptine / dantrolene: no more useful than routine supportiveBromocriptine / dantrolene: no more useful than routine supportive
carecare

23. Catatonia/NMSCatatonia/NMS Catatonia: primaryCatatonia: primary corticalcortical disorderdisorder
 NMS: primaryNMS: primary basal gangliabasal ganglia disorder w/ secondarydisorder w/ secondary
involvement of cortical motor structuresinvolvement of cortical motor structures
 Both Catatonia & NMS areBoth Catatonia & NMS are variants of the same disorder –variants of the same disorder –
 Catatonic & NMSCatatonic & NMS involve same loopsinvolve same loops (orbito-frontal/motor)(orbito-frontal/motor)
 Differ in kinds of modulationDiffer in kinds of modulation, i.e., i.e.
CatatoniaCatatonia: cortical-subcortical top down: cortical-subcortical top down vs.vs.
NMSNMS: subcortical-cortical bottom-up: subcortical-cortical bottom-up, both involving, both involving
GABAergic, dopaminergic and glutamatergic transmissionGABAergic, dopaminergic and glutamatergic transmission
 Simple catatonia / MC / NMS share a commonSimple catatonia / MC / NMS share a common
pathophysiology involving reduced dopaminergicpathophysiology involving reduced dopaminergic
functioning in the basal ganglia-thalomocortical circuitsfunctioning in the basal ganglia-thalomocortical circuits
 Catatonia: psychomotor disorder & NMS: motor disorderCatatonia: psychomotor disorder & NMS: motor disorder

24. CatatoniaCatatonia
No identifying clinical or laboratory characteristics thatNo identifying clinical or laboratory characteristics that
distinguish catatonia from NMSdistinguish catatonia from NMS
 AAutonomic instabilityutonomic instability ((↑↑↑↑↑↑ HR > ↑ BP)HR > ↑ BP)
 LLeukocytosis: common but nonspecificeukocytosis: common but nonspecific
 ↑↑Creatine Phosphokinase (CPK): from skeletal muscleCreatine Phosphokinase (CPK): from skeletal muscle
 ↓↓Serum Iron: MC w/ low serum Fe, coupled w/neurolepticsSerum Iron: MC w/ low serum Fe, coupled w/neuroleptics
will leads to NMSwill leads to NMS
There are no specific diagnostic test for CatatoniaThere are no specific diagnostic test for Catatonia
Leukocytosis, elevated CPK and low serum Fe may be usedLeukocytosis, elevated CPK and low serum Fe may be used
as an adjunct in the dx of Malignant Catatonia & NMSas an adjunct in the dx of Malignant Catatonia & NMS

25. Treatment of CatatoniaTreatment of Catatonia
PharmacotherapyPharmacotherapy
Electroconvulsive TherapyElectroconvulsive Therapy

26. CatatoniaCatatonia
proposed pathophysiologyproposed pathophysiology
 GABA-Glutamate HypothesisGABA-Glutamate Hypothesis
• GABAGABAAA hypo-activityhypo-activity
• Glutamate-NMDA hyper-activityGlutamate-NMDA hyper-activity
 Dopamine-2 hypo-activity (NMS)Dopamine-2 hypo-activity (NMS)
 Serotonin-2 hyper-activitySerotonin-2 hyper-activity
 Cholinergic hyper-activityCholinergic hyper-activity

30. TreatmentTreatment
The long-term prognosis appears to be most closelyThe long-term prognosis appears to be most closely
linked to successful treatment of the underlyinglinked to successful treatment of the underlying
conditioncondition
►GABA Agonist (BZDs & zolpidem)GABA Agonist (BZDs & zolpidem)
►Electroconvulsive Therapy (ECT)Electroconvulsive Therapy (ECT)
► Amobarbital: ?tx of catatonic mutism – only one double-Amobarbital: ?tx of catatonic mutism – only one double-
blind RCS published 15 yrs ago found amobarbital wasblind RCS published 15 yrs ago found amobarbital was
superior to salinesuperior to saline (McCall, et al;(McCall, et al; Am J Psychiatry ’92)Am J Psychiatry ’92)

31. Pharmacotherapy ofPharmacotherapy of
CatatoniaCatatonia
►GABA promotors (BZD, Zolpidem)GABA promotors (BZD, Zolpidem)
►Certain AEDs (Valproate, CBZ,Certain AEDs (Valproate, CBZ,
TopiramateTopiramate
►Glutamate inhibitors (Memantine)Glutamate inhibitors (Memantine)
►SGAs (Clozapine)SGAs (Clozapine)
►Dopaminergic Agents (Amantadine)Dopaminergic Agents (Amantadine)

32. TreatmentTreatment
GABA AgonistGABA Agonist: strong GABA: strong GABAAA potencypotency
► Benzodiazepines … lorazepam, diazepamBenzodiazepines … lorazepam, diazepam
► Zolpidem (Ambien)Zolpidem (Ambien)
AEDsAEDs: anticonvulsants: anticonvulsants
GABA agonist (*) & Anti-glutamate potency (#)GABA agonist (*) & Anti-glutamate potency (#)
***Valproic Acid (Depakote) #***Valproic Acid (Depakote) #
**Carbamazepine (Tegretol) #**Carbamazepine (Tegretol) #
*Topiramate (Topamax) ##*Topiramate (Topamax) ##

33. TreatmentTreatment
Glutamate InhibitorsGlutamate Inhibitors::
Non-competitive NMDA antag / Anti-glutamate potency (#)Non-competitive NMDA antag / Anti-glutamate potency (#)
► Memantine (Namenda) (##)Memantine (Namenda) (##)
► Amantadine (#) – worsens psychosisAmantadine (#) – worsens psychosis
SGAs: all Anti-5-HTSGAs: all Anti-5-HT2A;2A; Anti-glutamate effects “?”Anti-glutamate effects “?”
(loose DA binding)(loose DA binding)
► Clozapine, Quetiapine, OlanzapineClozapine, Quetiapine, Olanzapine
(tight DA binding)(tight DA binding)
► Risperidone, ZiprasidoneRisperidone, Ziprasidone
Dopaminergic agentsDopaminergic agents: Carbidopa/levodopa; bromocriptine: Carbidopa/levodopa; bromocriptine
no anti-glutamate effects / worsens psychosisno anti-glutamate effects / worsens psychosis

34. TreatmentTreatment
►GABA Agonist:GABA Agonist: Benzodiazepines (BZDs)Benzodiazepines (BZDs)
GABA-ergic pathways inhibit dopaminergic blockadeGABA-ergic pathways inhibit dopaminergic blockade
in the mesolimbic & mesostriatal pathwaysin the mesolimbic & mesostriatal pathways
responsible for the catatonic stateresponsible for the catatonic state
► BZDsBZDs interrupt the anxiety component of the catatonicinterrupt the anxiety component of the catatonic
state. Ungvari et al (’94-’98) postulated the concept of ‘briefstate. Ungvari et al (’94-’98) postulated the concept of ‘brief
psychotic rx’ or ‘hysterical cataleptiform conversion’ inpsychotic rx’ or ‘hysterical cataleptiform conversion’ in
which anxiety is at the core of the volitional & behavioralwhich anxiety is at the core of the volitional & behavioral
signs (‘Nervous Breakdown’)signs (‘Nervous Breakdown’)

35. TreatmentTreatment
►GABA Agonist:GABA Agonist: Benzodiazepines (BZDs)Benzodiazepines (BZDs)
Nonmalignant catatonia: (Ativan) …Nonmalignant catatonia: (Ativan) …
lorazepam: 2mg IM initially, then q3H; 6-20mg/daylorazepam: 2mg IM initially, then q3H; 6-20mg/day
 % responders w/complete remission approx. 75%% responders w/complete remission approx. 75%
 initiate ECT on 5initiate ECT on 5thth
day afterday after inadequateinadequate responseresponse
 lorazepam therapeutic challenge test …lorazepam therapeutic challenge test …
1 mg lorazepam i.v.1 mg lorazepam i.v. →→ wait 5’ for a response; if nowait 5’ for a response; if no
response then repeat process … nonresponseresponse then repeat process … nonresponse
doesn’t preclude future BZD response, althoughdoesn’t preclude future BZD response, although
higher doses are necessary & concurrenthigher doses are necessary & concurrent
preparation for ECT should be initiatedpreparation for ECT should be initiated

36. TreatmentTreatment
► GABA Agonist:GABA Agonist:
zolpidem (Ambien):zolpidem (Ambien): rapid –onset short actingrapid –onset short acting
imidazopyridine hypnotic (bind to GABA-A)imidazopyridine hypnotic (bind to GABA-A)
► (FR)(FR) zolpidemzolpidem therapeutic challenge test …therapeutic challenge test …
► 10mg admin orally w/ + response, AEB a decrease10mg admin orally w/ + response, AEB a decrease
in catatonic sxsin catatonic sxs
► mean time of response - 32 min. after dosemean time of response - 32 min. after dose
► effect lasted a mean of 185 mineffect lasted a mean of 185 min (relationship between(relationship between
improvement of sxs and plasma conc of 80-150 ng/L)improvement of sxs and plasma conc of 80-150 ng/L)
► OnlyOnly transitory reversaltransitory reversal of catatoniaof catatonia

38. TreatmentTreatment
Electroconvulsive Therapy (ECT)Electroconvulsive Therapy (ECT)
Bitemporal (BL) electrode placement w/brief-pulseBitemporal (BL) electrode placement w/brief-pulse
current – initial energy started at ½ pt’s agecurrent – initial energy started at ½ pt’s age
Malignant Catatonia / NMSMalignant Catatonia / NMS:: daily for 6 txs … (endaily for 6 txs … (en
blocbloc)?)?
► Hawkins, et al.; “Somatic Tx of Catatonia”,Hawkins, et al.; “Somatic Tx of Catatonia”,
Int JInt J Psychiatry MedPsychiatry Med. 1995; 25(4):345-369. 1995; 25(4):345-369
 literature review -pts. who met DSM-IV criteria forliterature review -pts. who met DSM-IV criteria for
catatonia – response rate ofcatatonia – response rate of 85%85% withwith ECTECT vsvs
response rate ofresponse rate of 70%70% withwith BZDsBZDs
 In Malignant Catatonia,In Malignant Catatonia, ECTECT produced aproduced a 89%89%
complete response rate vs. acomplete response rate vs. a 40%40% completecomplete
response rate withresponse rate with BZDsBZDs

39. TreatmentTreatment
““Electroconvulsive Therapy for Catatonia”Electroconvulsive Therapy for Catatonia”
Journal of ECTJournal of ECT (V26, #4, December 2010); Waarde, et al.(V26, #4, December 2010); Waarde, et al.
► Retrospective study of 27 pts with catatonia whoRetrospective study of 27 pts with catatonia who
had ECT (CGI-I scale)had ECT (CGI-I scale)
► Most benefited (59%)*Most benefited (59%)*
► esp. younger w/autonomic dysregulationesp. younger w/autonomic dysregulation
► daily admin more effectivedaily admin more effective
► longer sz act at the final tx = > responselonger sz act at the final tx = > response
*McCall (88%) & Rohland (93%)*McCall (88%) & Rohland (93%)

40. CatatoniaCatatoniaDSM-V workgroup - Proposed Revision toDSM-V workgroup - Proposed Revision to DSM-VDSM-V::
Why?Why?
Catatonia often not recognized / better recognition wouldCatatonia often not recognized / better recognition would
facilitate proper treatment (e.g. early intervention w/BZDfacilitate proper treatment (e.g. early intervention w/BZD
&/or ECT)&/or ECT)
? Catatonia a? Catatonia a Movement DisorderMovement Disorder
? Catatonia an? Catatonia an Expression of Extreme AnxietyExpression of Extreme Anxiety
? Catatonia as a? Catatonia as a type of Seizure Disordertype of Seizure Disorder
? Catatonia a? Catatonia a State of Extreme InhibitionState of Extreme Inhibition
Changes? Two alternative possible modifications:Changes? Two alternative possible modifications:
#1#1 Establish a separate psychiatric diagnostic classificationEstablish a separate psychiatric diagnostic classification
(similar to Delirium) –(similar to Delirium) –
 add duration criterion to enhance reliabilityadd duration criterion to enhance reliability
 add a specifier indicating which diagnosis is co-morbidadd a specifier indicating which diagnosis is co-morbid

41. CatatoniaCatatonia
Proposed Revision toProposed Revision to DSM-VDSM-V
Proposed Dx Criteria for CatatoniaProposed Dx Criteria for Catatonia
A.A. Immobility, mutism, or stupor ofImmobility, mutism, or stupor of at least 1 hrs durationat least 1 hrs duration, assoc. with at, assoc. with at
least one of the following: catalepsy, autonomic obedience, or posturing,least one of the following: catalepsy, autonomic obedience, or posturing,
observed or elicited on two or more occasionsobserved or elicited on two or more occasions
B.B. In the absence of immobility, mutism, or stupor, at least two of theIn the absence of immobility, mutism, or stupor, at least two of the
following, which can be observed or elicited on two or more occasions:following, which can be observed or elicited on two or more occasions:
stereotypy, echophenomena, catalepsy, autonomic obedience, posturing,stereotypy, echophenomena, catalepsy, autonomic obedience, posturing,
negativism, gegenhalten, ambitendencynegativism, gegenhalten, ambitendency
Proposed Categories for Dx Classification of CatatoniaProposed Categories for Dx Classification of Catatonia
DSM code xxx.1 Nonmalignant catatonia (Kahlbaum Syndrome)DSM code xxx.1 Nonmalignant catatonia (Kahlbaum Syndrome)
xxx.2 Delirious Catatonia (delirious mania, excited catatonia)xxx.2 Delirious Catatonia (delirious mania, excited catatonia)
xxx.3 Malignant catatonia (MC, NMS, Serotonin Syndrome)xxx.3 Malignant catatonia (MC, NMS, Serotonin Syndrome)
SpecifierSpecifier
DSM code xxx.x1 Secondary to a mood disorderDSM code xxx.x1 Secondary to a mood disorder
xxx.x2 Secondary to a GMCxxx.x2 Secondary to a GMC
xxx.x3 Secondary to a neurological disorderxxx.x3 Secondary to a neurological disorder
xxx.x4 Secondary to a psychotic disorderxxx.x4 Secondary to a psychotic disorder
#2#2 Place catatonia criteria as aPlace catatonia criteria as a specifierspecifier in the mood, GMCin the mood, GMC
and psychosis sectionand psychosis section

42. Catatonia: SummaryCatatonia: Summary
Catatonia is currently considered to be aCatatonia is currently considered to be a psychomotorpsychomotor
syndromesyndrome as aas a final commonfinal common functional pathwayfunctional pathway ofof
psychiatric (primarily affective) & medical disorderspsychiatric (primarily affective) & medical disorders
 up to 5% of adult psych admitsup to 5% of adult psych admits
 GABA-Glutamate Hypothesis;GABA-Glutamate Hypothesis;
GABAGABAAA hypo & Glutamate-NMDA hyper-activity (MC)hypo & Glutamate-NMDA hyper-activity (MC)
 Dopamine-2 hypo-activity (NMS)Dopamine-2 hypo-activity (NMS)
 Serotonin-2 hyper-activity (SS)Serotonin-2 hyper-activity (SS)
All involve the same circuit:All involve the same circuit: basal ganglia-thalomocorticalbasal ganglia-thalomocortical
TreatmentTreatment: (1) treatment of the underlying condition: (1) treatment of the underlying condition
** hold neuroleptics if MC suspect** hold neuroleptics if MC suspect
(2) BZDs / ECT(2) BZDs / ECT
to re-equilibrate neurotransmitters / ? raise seizure thresholdto re-equilibrate neurotransmitters / ? raise seizure threshold

44. Any questions ???Any questions ???
Stay tuned